Provider Demographics
NPI:1861417859
Name:JACKSON, KRISTIN M (MD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E PRINCETON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5553
Mailing Address - Country:US
Mailing Address - Phone:407-303-1444
Mailing Address - Fax:407-303-1446
Practice Address - Street 1:235 E PRINCETON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5553
Practice Address - Country:US
Practice Address - Phone:407-303-1444
Practice Address - Fax:407-303-1446
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 89065207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268416100Medicaid
FL82467ZMedicare ID - Type Unspecified
FLH55982Medicare UPIN